Nursing Elites

1. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns.
• B. Support the family's decision and initiate life-sustaining measures.
• C. Complete an incident report.
• D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

2. Prior to a thoracentesis, which of the following actions should the nurse take?

• A. Position the client in an upright position, leaning over the bedside table.
• B. Explain the procedure.
• C. Obtain ABGs.
• D. Administer benzocaine spray.

Correct answer: A

Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.

3. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

• A. Store the glasses in a labeled case.
• B. Clean the glasses with hot water
• C. Clean the glasses with a paper towel.
• D. Store the glasses on the bedside table.

Correct answer: A

Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.

4. When discussing group treatment and therapy with a client, which characteristic should the nurse include as being a characteristic of a therapeutic group?

• A. The group is organized in an autocratic structure.
• B. The group encourages members to focus on a particular issue
• C. The group must be led by a licensed psychiatrist.
• D. The group encourages clients to form dependent relationships.

Correct answer: B

Rationale: In therapeutic groups, the focus is often on addressing specific issues or topics. This approach allows group members to concentrate on their concerns, share experiences, and work towards common goals. Autocratic structures, mandatory leadership by a licensed psychiatrist, or fostering dependent relationships are not typical characteristics of therapeutic groups.

5. A client with depression reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudoparkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: When St. John's wort, an herbal supplement, is taken with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of serotonin syndrome. Serotonin syndrome is a serious condition that can occur when there is an excess of serotonin in the body, leading to symptoms such as confusion, hallucinations, rapid heart rate, increased body temperature, and more. Monitoring for serotonin syndrome is crucial when these substances are taken together to prevent any potential harm to the client.

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